Neurology

inordinately high incidence of coronary artery disease, he said: In a group of 20 men, everyone of whom I knew personally, the outstanding feature was the incessant treadmill of practice; and yet if hard work-that "badge of all our tribe"-was alone responsible would there not be a great many more cases? Everyone of these men had an added factor-worry. To temper this belief, also, Hinkle and his colleagues found that the "stresses and tensions of daily life" appeared to be equally great for employees from all levels, and that executives had no monopoly of the cares of the world.

OOTOBER 12,1968 inordinately high incidence of coronary artery disease, he said: In a group of 20 men, everyone of whom I knew personally, the outstanding feature was the incessant treadmill of practice; and yet if hard work-that "badge of all our tribe"-was alone responsible would there not be a great many more cases? Everyone of these men had an added factor-worry. To temper this belief, also, Hinkle and his colleagues found that the "stresses and tensions of daily life" appeared to be equally great for employees from all levels, and that executives had no monopoly of the cares of the world.
The Cornell group admit that it is important not to over-generalize from observations on Bell System employees to men throughout the world, though their series is surely large enough and typical enough of contemporary western society to shatter the myth of the particular vulnerability of modern executives to coronary heart disease. However, the authors believe the most important implications of the data have to do with the origins of coronary artery disease. They show that there are important determinants of the risk of heart disease already in existence before men reach adult life, and that a pattern once established is not greatly influenced by subsequent experiences or behaviour.

ARTISTIC POSSESSIONS AT THE ROYAL COLLEGE OF SURGEONS
ONE of the most satisfying pleasures for a visitor to the Royal CoIl eKe of Surgeons in Lincoln's Inn Fields is the profusion of portraits, in both oil and marble, of the great figures in British surgery, the furniture of all styles and quality, the pharmacy jars, old surgical instruments (most of them unfortunately no longer on display) and, on festive occasions, the large collection of silver. These artistic possessions are in such profusion that it is difficult, if not impossible, for a visitor to get a grasp of their scope.
A catalogue of. the portraits was prepared by Mr. W. R.
Le Fanu, the Librarian, and published in 1960, and now we have an equally well-illustrated catalogue of the furniture, pharmacy jars and silver prepared by Sir Victor Negus.' The publication of this was made possible by a generous benefaction from the estate of the late Sir Hugh Lett, a former President of the College and Chairman of the Hunterian Trustees.
Sir Victor Negus, himself a Hunterian Trustee, is well known for his meticulous work on the comparative anatomy of the larynx and of respiration, as well as for his history of the Hunterian Trustees. Now, with devoted care and obvious enthusiasm for his task, he has prepared a description of the artistic possessions of the College. He modestly understates his knowledge, and gives generous acknowledgement to those to whom he has turned for assistance. The result is an excellent catalogue of the College's possessions, of which historically the most important is the magnificent collection of drug jars, the majority of which were left to the College by Sir St. Clair Thomson on his death in 1942. Much of the silver is relatively modern, but there are a number of important pieces of the eighteenth century silversmiths; all items are carefully described and many illustrated. The College silver is only rarely seen by a visitor unless he should attend a formal dinner, and thus is not so apparent to the eye as the portraits, busts and furniture.
Sir Victor deserves the thanks of all who have the interests of the Royal College of Surgeons at heart for his painstaking work. His book is of particular interest for the reference to the donors of each piece. The generosity of Sir John Bland-Sutton, Lord Webb-Johnson and many others is now s-een, and it is nice to note that Australian surgeons and the Royal Australasian College of Surgeons are among those who have added furniture and silver to the collection.
Unfortunately the price of this book in Australia will prevent many who might wish to buy it from the pleasure of its perusal. We deplore the fact that a not unreasonable £5 5s. sterling is translated into $18.40. THE obstetrical histories before the onset of illness was obtained from a national series of patients in Israel with multiple sclerosis and from controls. No significant differences were found between patients and controls In a number of pregnancies, deliveries and abortions. However. a significantly higher percentage of the patients reported a pregnancy In the year before onset, while relatively more controls had been pregnant one to two years before the age of onset. The percentage reporting pregnancies three or more years before onset was not significantly different in patients and controls. The results suggest that pregnancy may on occasion precipitate the onset of multiple sclerosis. The period of danger Is during the last two years before the onset of clinical symptoms, and may correspond to aa incubation period or premorbld state during which a variety of factors, including pregnancy, may precipitate demyelination of the central nervous system. THE authors describe eight females In two generations affected by a slowly progressive limb-girdle type of muscular dystrophy. Muscle biopsies revealed Isolated muscle fibre necrosis and phagocytosis with classic myopathic changes seen in only one of the four biopsy specimens. This necrotizing myopathy is compatible with muscular dystrophy. The authors examined various theories to account for the limitation of the disease to the females, and a theory of an autosomal dominant mode of inheritance with the expression limited: to females is put forward as the best explanation. THE authors report a patient with generalized Hodgkin's disease who had peripheral neuropathy, diabetes insipidus and terminal hallucinatior.s. Intracerebral Hodgkin's granuloma was found at post-mortem examination, which involved the hypothalamus, fornix, the septum pellucldurn, optic nerves, optic chiasm, left fifth cranial nerve, medulla and spinal cord. The thyroid gland, breast, lung and stomach were also involved, but the reticuloendothelial system was spared. The distribution of the lesion is one which, the authors point out, has not been reported before. THE authors report thirteen patients with bony abnormalities of the cervical region accompanied by neurological deficits, and they attempt to categorize the neurological syndromes. (1) Cord: compression with a spastic tetraparesis and varying degrees of sensory deficit. Three of these four patients had dissociation of the odontoid process, and the fourth suffered occipitalization of the atlas. (2) Myelopathy. Three patients had spastic tetraparesis which was slowly progressive, but myelography showed no evidence of cord compression. The definitive cause for the neurological deficit was unknown. THE authors report a patient in whom Wernicke's encephalopathy occurred as a complication of chronic ureemla, and its management by dialysis. In addition, evidence of central pontine myelinolysis was present. This unique association in a patient of this type served to emphasize the importance of nutritional factors in the pathogenesis of these conditions. The related complex metabolic disturbances that may occur in the treatment of chronic renal disease are briefly discussed, including the effect of dialysis upon serum levels of vitamins, the effective elevated blood glucose levels upon t.he reserves of some vitamins, and the role of chronic infection upon the rate of utilization of vitamins.
THE authors point out. that in systemic lupus erythematosus acute organic mental svnromes, cerebrovascular disorders and epilepsy, chorea, Gufllatn-Barre syndrome, subarachnoid hremorrhage, peripheral neuropathy and cranial nerve palsies are not. infrequent, but myelopathies have been rarely reported. They report four patients with myelopathy in which L.E. cell preparations were "positive" in all four, and symptoms of fever, anremia, leukopenia or hyperglobullnremia were present. Pathological study revealed necrotic softening of the thoraco-lumbar cord, with areas of myelomalacia. Small hremorrhagic foci were present near areas of myelomalacia. SYMPATHETIC DEFICITS FOLLOWING THALAMOTOMY. P. W. Carmel, Arch. Neurol. (Ohic.) , 1968, 18 : 378-387 (April).
THE author reviewed sympathetic deficits found in 15 of 38 patients who had undergone thalamotomy for dyskinesia, These deficits consisted' of ptosis, miosis and hemianhydrosis on the side of the body ipsilateral to the site of the lesion. Abnormalfttes were documented by pupillography, starch-iodine sweat testing and measurement of skin resistance. The locus of the lesion was verified by X-ray films taken with the coagulation probe at. the site of the lesion. The anatomical area common to all patients who demonstrated the syndrome was the pre-rubral field and capsule of the red nucleus. Physiological and anatomical experiments indicate that this area contains efferent hypothalamic pathways. These clinical data suggest that central descending sympathetic pathways may be circumscribed at upper mesencephalic levels, and perhaps may be selectively interrupted by stereotaxic lesions.
THE authors reviewed 50 cases of fibrous dysplasia of the skull. The neurological complications they found 'were visual impairment secondary to optic nerve compression, and conductive hearing loss due to auditory nerve compression. Epileptic seizures occurred in six patients. No other neurological abnormalities were found. THROMBOTIC THROMBOCYTOPENIC PURPURA. A. Silverst.ein, Arch. Neurol. (Ohic.), 1968, 18: 358-362 (April).
THlil author reviews the clinical manifestations of thrombotic thrombocytopenic purpura, including hremolytic anremia, thrombocytopenia, fever, renal involvement and neurological manifestations. The condition is characterized pathologically by occlusion of small blood vessels in many organs by homogenous, eosinophilic matter. Neurological involvement occurs in over 90% of the patients with the condition, and the illness begins as a neurological one in 47%. They found that less than 50% of the patients who had neurological involvement improved after their initial lesion was diagnosed. THE authors report a questionnaire survey of 861 Scandinavian women Who had recently given birth. In contrast to many similar investigations carried out on psychiatric patients, this investigation was performed on a sample of the populatlon which was representative of all women who had delivered a baby in hospital. More than 99% of the women in the area gave birth in hospital so the sample was representative of all parous women-that is to say, it was a normal sample and could not readily be compared with controls. In three-fifths of the 861 women there was an increased incidence of psychiatric symptoms with an increasing number of full-term pregnancies. The remaining two-fifths remained symptom-free regardless of parity. Age, social class, earlier psychiatric history, or attitude towards the pregnancy did not differentiate these two groups, although earlier psychiatric history and attitudes towards pregnancy were both highly correlated with the frequency of post-partum mental disorder. Multiparre were more often healthy until delivery and showed a lower frequency of minor psychiatric symptoms during pregnancy. This may indicate either that mentally healthier women tend to have more children, or that multlparee are more used to slight discomfort during pregnancy and tend to ignore it.

MENTAL ILLNESS IN PARENTS OF PHENYLKETONURIC CHILDREN.
M. D. Blumenthal, J. Psuchiat. Res., 1967, 5: 59-74. PHENYLKETONURIA is a recessive hereditary disease usually associated with severe mental deficiency, although an increasing number of patients have been reported to have normal or borderline intelllgence. Many patients with normal or near normal intelllgence appear to suffer from behavioural disturbances, so that some of these have been misdiagnosed as having autism or organic brain damage. Relatively little is known about the characteristics of the heterozygous carrier for this disease. It has been suggested that persons heterozygous for phenylketonuria are more apt to suffer from psychopathology than other Individuals. The author presents a review of the relevant literature and goes on to report a study of persons presumed heterozygous for phenylketonuria, located through their phenylketonuric children. The main part of the investigation consisted of a standard Interview designed to evaluate a variety of mental health areas. Interviewing was completed in 91 % of the sample. One hundred and fifty-eight men and 173 women were tested. Decreasing social class was associated with increasing scores for mental ill-health. The parents of phenylketonuric children did not score differently from control groups of parents with non-phenylketonuric mentally retarded offspring. and of parents of children with cystic fibrosis. This would indicate that these heterozygotes were not more susceptible to mental health problems than the controls.